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The form explains that the employee requesting leave must complete the certification and submit the required claim forms and documentation for Arch Insurance review to determine eligibility and benefit amount. 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The submitted certification is shared with Arch Insurance and the employee’s employer.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How can leave be taken under Maine Paid Family and Medical Leave?",{"text":114,"@type":110},"Leave may be taken continuously, intermittently, or on a reduced leave schedule. The form requires specifying whether dates are estimated and entering the relevant leave start/end or intermittent leave dates.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the employee notify the employer about the leave request?",{"text":118,"@type":110},"If the leave is foreseeable, the employee must notify the Maine employer within 60 days before the leave start date. 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Arch Insurance will review all submitted claims to determine your eligibility for benefits. The employee who is applying for leave must complete this certification. This certification will be shared with Arch Insurance and your employer* .\u003Cbr>Before you apply for ME PFML... |  |  |  |  |\n| --- | --- | --- | --- | --- |\n|  Check eligibility requirements for leave |  |  |  Plan your leave. Leave can betaken continuously, intermittently, or on a reduced leave schdeule in accordance with ME Paid Family and Medical Leave. |  Notify your ME employer within 60 days before the start of leave (if the leave is foreseeable) . Otherwise, notify your employer as soon as possible. |\n| Complete your claim form(s) and attach required documentation\u003Cbr>\u003Cbr>Application for Maine Paid Family and Medical Leave | Family Member’s Serious Health Condition |  |  |  |  |\n| Part A: |  | Employee Information\u003Cbr>(to be completed by the employee requesting leave) |  |  |\n| | Employee’s Legal Name:  \u003Cbr>(First Name, Middle Initial, Last Name)\u003Cbr>Employee’s Mailing Address:\u003Cbr>Street Address line 2 City State |     | Zip |           | Social Security Number:       -     -        \u003Cbr>m m d d y y y y\u003Cbr>Employee’s Date of Birth: |     / |     / |         | |  |  |  |\n\n5 Why are you applying for leave?  \n􀂉 A family member’s serious health condition that is related to military service.  \n􀂉 A family member’s serious health condition.  \n*Benefits described within are underwritten by Arch Insurance Company, NAIC \\#11150, a member company of Arch Insurance Group Inc. (“Arch”) . Please refer to your policy for detailed terms and conditions. The information you provide to Arch on this form will be used to administer PFML benefits. In order to process your claim application, and determine your eligibility and benefit amount, Arch may share your information with your current and/ or past employer(s), and PFML Partners.  \n[Visit](Visit archinsurance.com/disability or)[ archinsurance.com/disability](Visit archinsurance.com/disability or)[ or](Visit archinsurance.com/disability or) call 877-369-0979 for more information. Questions? Contact us at 877-369-0979 [or find us online at](or find us online at archinsurance.com/disability)[ archinsurance.com/disability](or find us online at archinsurance.com/disability)  \n26-06-DBL08  \nPage 2  \nApplication for Maine Paid Family and Medical Leave | Family Member’s Serious Health Condition  \nPart A Continued  \nEmployee’s Gender: 􀂉 Male 􀂉 Female 􀂉 Non-Designated / Other  \n\n| Employee’s Phone \\#: (       ) - |       | - |         | |\n| --- |\n| Employee’s Email Address:   |\n\n9 Select the family member to you. The family member is your:  \n􀂉 Child (of any age) 􀂉 Spouse 􀂉 Domestic Partner  \n􀂉 Parent or your Spouse/Domestic Partner’s Parent  \n􀂉 Sibling or your Spouse/Domestic Partner’s Sibling  \n􀂉 Grandparent or your Spouse/Domestic Partner’s Grandparent  \nRelationships include: biological, foster, adoptive, step, and in loco parentis relationships and the same relationships to the employee’s spouse or domestic partner, if applicable.  \n􀂉 Grandchild or your Spouse/Domestic Partner’s Grandchild  \n􀂉 Person with whom the employee has a significant bond that is or is like a family relationship 10 Employer Information:  \nName  \n| Street |\n| --- |\n| Address line 2 |\n\nCity  \nState |     | Zip |           |  \nAvg \\# Hours Worked/Week |   | Avg \\# Days Worked/Week |   | Avg Wages ($) |   |  \n10a List all additional employers from the past year:  \nEmployer \\#1 Name  \n\n| Street |  |\n| --- | --- |\n| Address line 2 |  |\n| City  State |     | Zip |           | Period of Employment:\u003Cbr>m m d d y y y y m m d d y y y y\u003Cbr>From |     / |     / |         | To |     / |     / |         |\u003Cbr>Avg \\# Hours Worked/Week |   | Avg \\# Days Worked/Week |   | Avg Wages ($","cbCaihkGhHQxNzje","https://ap.wps.com/l/cbCaihkGhHQxNzje","pdf",545678,"English","# Certification and eligibility\n## Before applying and notification timing\n# Claim form sections\n## Employee information\n## Family relationship selection\n## Employer information\n# Leave details and benefits questions\n## Leave duration type and dates\n## Advanced notice and benefit history","[{\"question\":\"What information must the employee requesting leave complete for Maine PFML?\",\"answer\":\"The employee must complete the certification and fill out the employee information portion of the claim form. The submitted certification is shared with Arch Insurance and the employee’s employer.\"},{\"question\":\"How can leave be taken under Maine Paid Family and Medical Leave?\",\"answer\":\"Leave may be taken continuously, intermittently, or on a reduced leave schedule. The form requires specifying whether dates are estimated and entering the relevant leave start/end or intermittent leave dates.\"},{\"question\":\"How does the employee notify the employer about the leave request?\",\"answer\":\"If the leave is foreseeable, the employee must notify the Maine employer within 60 days before the leave start date. Otherwise, the employee should notify the employer as soon as possible.\"}]","Maine Paid Family and Medical Leave - Family Member’s Serious Health Condition - Application Guidance | PDF",1789832901]